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Tendon injuries are extremely common and chances are that most people will experience one at some point in their life. They can be confusing and scary, especially when they are recurrent or not improving.
We see many patients who are worried about their ultrasound findings which may say they have degenerative areas within their tendon. There is lots of research that has been done recently that shows us that even in a tendon with degeneration, there is plenty of healthy tendon that is capable of being strengthened and exercised which will allow the person to recover from their injury.
Do Tendons heal?
Many patients are worried about damage to their tendon and whether it will heal. The important thing to understand first is that a torn tendon is different to a finding of tendinopathy (I will explain tendinopathy in greater detail later). Also, the degree of the tear is significant – a partial vs a complete tear. Tendons are poor at healing as they do not have a good blood supply. Whilst tendon tears often do not to heal, a partial tear may settle down without any invasive intervention if appropriately rehabilitated by strengthening the tendon and surrounding musculature. A complete tear tendon will not heal, and should be referred for specialist review as it may require surgical intervention.
What are the symptoms of a torn tendon?
When a tendon completely tears (ruptures) patients usually report that they felt “something go” or “snap” and it will be accompanied by swelling, which later becomes bruising. Also, the joint that attached to the tendon may no longer work normally. For example, a patient with a ruptured Achilles will not be able to point their foot against even slight resistance.
What is tendinopathy?
Tendinopathy is by far the most common type of tendon injury. Tendinopathy refers to the tendon being in a state of overload which may present as pain. Contrary to common belief, the tendon is usually not inflamed and this is why we no longer use the term ‘tendonitis’, as the ‘itis’ means inflammation, which is generally incorrect. The importance of this distinction is that an inflamed tendon will need some rest, and possibly some anti-inflammatories, to help settle it down before doing any strengthening exercises.
Conversely, whilst an overloaded tendon in a state of tendinopathy may feel better when resting, the problem will be there waiting for you when you start exercising again. In fact, patients often get stuck in a vicious cycle where they rest and then start exercising when their pain has settled, only to find the pain returns and often comes on more easily this time. This can be very confusing and frustrating for patients but can be explained in that the tendon has become weak through resting and disuse and therefore its tolerance to loading has reduced, making it overload more easily.
Therefore, a patient with tendinopathy will respond better to a rehabilitation regime consisting of strengthening exercises that gradually increase the tendon’s tolerance to loading over time.
The take home message here is that if you have tendinopathy, then your tendon does not need rest, it will need a graduated strengthening program usually over an 8-12 week period. It is important that these exercises are prescribed by a physiotherapist with specific expertise in treating tendon problems.
How do you treat a tendon injury?
Tendon treatment varies depending on the type of injury. A ruptured tendon will need review with a specialist to determine the appropriate course of action. This may include immobilisation in a cast or surgery. A partial tendon tear is often treated conservatively (non-operatively) initially, and then if the patient is failing to improve, specialist review and surgical review may be considered.
At Sydney Physiotherapy Solutions, our Tendinopathy patients are placed into our Sydney Tendon Clinic. It uses the latest in scientific research on Tendinopathy and is regularly updated as new research is released. The Clinic guides patients through the recovery process which consists of four stages.
Stage 1 includes treatments aimed at controlling pain and removing activities that are overloading the tendon. The goal of stage 1 is to make the patient’s symptoms stable (nil or low-level pain that does not flare up) and also to address any weakness or biomechanical problems that may have contributed to the problem in the first place. Stage 1 also consists of educating the patient as to the cause of their problem and also how to monitor their own progress to avoid flare-ups.
Stage 2 consists of slow, heavy resistance exercises that have been shown through research to strengthen the tendon which improves patient’s tolerance to exercise and activities of daily living.
Stages 3 and 4 consists of increasing the speed and power of the tendon as well as introducing sport-specific exercises. Treatment programs are individualised to suit each patient’s needs and are delivered by a physiotherapist with specific expertise in tendon rehabilitation. Patients should anticipate an 8-12 week program, but for longstanding tendon problems, it can take 6 months to build up the appropriate strength due to the level of deconditioning that may be present initially. Read more.
What causes tendon injuries?
Tendon injuries result when either a repetitive or one-time load of the tendon exceeds the tendon’s tolerance for load. Tendon tolerance to load is dependent on your activity profile. For example, the Achilles tendon of Person A, who has been a runner for 5 years, running three times per week, is going to be used to more forceful and frequent loading than person B, who only walks every day and does not run for exercise. If person B decided to take up running, they would need to gradually increase their running distances to reduce the likelihood of overloading their tendon.
Other less common causes of tendon injuries include from a direct blow to the tendon or from highly repetitive friction such as may occur with a pair of shoes that rub on your heel/Achilles region.
How is a tendon injury diagnosed?
Most tendon injuries can be diagnosed in the clinic by an appropriately skilled clinician. Patients usually point with one finger to the area of their tendon injury and rarely report a large area of pain. Ultrasound can sometimes be useful for assisting diagnosis when other possible diagnoses need to be excluded. However, I often recommend that patients have an ultrasound of both the left and right sides (even if only one side is painful) so that we can make a comparison of what is normal for them. It is not uncommon to find some tendinopathy on the unaffected side too which reinforces the point that it is overload the tendon from too much exercise, too quickly, that causes the patient to experience pain, not the quality of the tendon. MRI is also sometimes used, especially if a full tear (rupture) of the tendon is suspected. Severe weakness in a tendon is suggestive of a large tear or rupture.
What is Tendonitis?
Tendonitis occurs when a tendon becomes inflamed. There is usually some swelling associated with this. Tendonitis is relatively rare and the term tendinopathy is the correct term used nowadays for a tendon injury that does not involve a torn tendon [see above]. Whether there is inflammation or not, the tendon has been overloaded and needs activity modification and then will likely also need to be strengthened to allow it to tolerate the exercise which caused the overload in the first place. So, tendonitis is treated as tendinopathy.
A graduated exercise program is the best way to avoid tendon problems.